Category Archives: Otolaryngology

Just a few years ago, tobacco and alcohol use were presumed to be the main causes of head and neck cancers. Evidence of oropharyngeal cancer associated with human papillomavirus (HPV) first appeared about 10 years ago, but it wasn’t until 2010, with the publication of 2 papers showing far greater survival among HPV-positive patients with head and neck cancer, that oncologists suddenly realized that they were likely dealing with two distinct diseases.

“It’s become clear that the disease we thought was one disease related to tobacco and alcohol is now being parsed into two major categories,” Dr. Maura L. Gillison said last week in Phoenix at the 2012 Multidisciplinary Head and Neck Cancer Symposium. At the meeting, she presented her group’s data showing that the overall prevalence of oral HPV infection in people aged 14-69 years is 6.9%, and that the prevalence is much higher among men than women. The Merck-supported trial paper was published online in JAMA on January 26, coinciding with her presentation.

Tissue section from a head and neck cancer patient / Courtesy of Tom Carey, Ph.D.

In a separate talk, Dr. Gillison summarized previous work from her group showing that the incidence of HPV-related cancer is rising while HPV-negative cancer is declining, consistent with the decline in tobacco use and changes in sexual behavior that increase HPV transmission. Overall survival of head and neck cancer has improved over the last decade, a trend that is likely due both to the improved prognosis among HPV-positive patients and to the decline in tobacco use rather than to advances in treatment, she said.

This recently heightened role of HPV in head and neck cancer – and the awareness of it – has impacted the field of oncology in several ways. For one, it has dramatically changed the way research is done, conference chair Dr. Ezra Cohen told me. “It has made a tremendous difference in the way clinical trials are conducted, because it makes absolutely no sense to lump these patients together. Now all clinical trials will either stratify for HPV status or design completely separate studies, because they truly are two biologically different diseases.”

Clinically, patients with head and neck cancers are now routinely tested for HPV. This wasn’t the case prior to 2010. And those who test positive are counseled differently, since their prognosis is better. Indeed, Dr. Cohen said, HPV-positive head/neck cancer patients appear to respond better to just about every type of treatment, including surgery.

What’s more, Dr. Gillison told me, HPV has essentially upended some of the tools oncologists use to predict outcomes in head and neck cancer patients. One example is the current tumor staging system, which doesn’t take into account HPV status. A Stage 3 or 4 cancer which carries a poor prognosis among HPV-negative patients might carry the prognosis now associated with Stage 1 cancer among those who are HPV-positive. And another factor that has been shown to predict poor outcome in HPV-negative patients, the presence of extracapsular extension, appears to have little impact in those who are HPV-positive.

“So all these things that we take as firmly established and drivers of treatment decisions in this new setting are all in question,” she said.

Tissue section from the same head/neck cancer, with brown stain of an HPV marker protein called p16 / Courtesy of Tom Carey, Ph.D.

Thus far there have been no major changes in treatment, but Dr. Cohen believes that is likely to change as more data become available. He is currently leading a clinical trial in collaboration with Novartis Pharmaceuticals looking at treatment with reduced radiation doses – and thereby reduced toxicity – for patients who have a good response to induction chemotherapy. Such patients are usually HPV positive.

Another study, funded by the National Cancer Institute, randomizes HPV positive patients to radiation combined with either chemotherapy or a monoclonal antibody, with the hypothesis that the latter will be better tolerated.

Dr. Cohen cautioned that treatment changes won’t come immediately. “Many of us in the field believe that there will be different therapies developed for [HPV-positive] patients, but it takes time to do that. It’s hard to make those changes, especially when we are curing the majority of these patients.”

Sleep is big business. People need it. They want it. They’ll spend money to get it. And, according to the bulk of presentations at the 25th annual joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Minneapolis (SLEEP 2011) last week, the demand for it continues to far outpace the supply. Given these conditions, it’s not surprising that Americans spend nearly $24 billion on sleep-related goods and services annually, and the market for insomnia drugs is predicted to grow by nearly 80%, to approximately $3.9 billion, in 2012, according to market research conducted by Marketdata Enterprises.

Image via Flickr user deansouglass by Creative Commons License.

Evidence of the anything-but-restful sleep market was plentiful in the SLEEP 2011 exhibit hall, with booth after booth of vendors showcasing everything from pharmaceuticals and nutraceuticals to earplugs, continuous positive airway pressure devices, breathing masks, light therapy boxes, aromatherapy sprays, premium mattresses, and customized pillows. There was also row upon row of posters highlighting the latest research on the multiple and varied sleep-related problems that are keeping the vendors in business.

During a walk through the exhibit hall, however, it didn’t take long for the ironic reality of the sleep conundrum to set in. Americans are spending billions of dollars on sleep-related goods and services and researchers are spending billions of dollars seeking insight into the global sleep deficit that, according to the meeting’s scientific program presentations, is leaving children, adolescents, and adults overtired, anxious, depressed, and suboptimally functional and is putting them at risk for a range of adverse health outcomes, including cardiovascular disease, asthma, diabetes, stroke, and obesity. Yet we, as a society, don’t value sleep.

For example, in March of this year, the Centers for Disease Control and Prevention reported that nearly one third of the country’s adults get less than the minimum recommended 7 hours of sleep per night, and it’s not because they’re not tired: nearly 40% of the survey population reported unintentionally falling asleep during the day and nearly 5% reported nodding off while driving in the preceding 30 days.

Notwithstanding suboptimal sleep quality or quantity resulting from chronic sleep disorders, such as insomnia, obstructive sleep apnea, restless leg syndrome, bruxism, narcolepsy, and sleepwalking, the country’s pervasive sleepiness is often a symptom of what has become a “24-hour society,” in which there’s not enough time in a day to do everything we want to do, according to Dr. Michel Cramer Bornemann, co-director of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center in Minneapolis. Not only have we become accustomed to trading sleep for work, he said in a session on sleep forensics, “we wear sleep deprivation as a badge of honor, as if lack of sleep is synonymous with hard work or achievement, when really it can impede both.”

Sleep is a biological imperative, Dr. Bornemann stressed. When it’s not valued as such, “everybody pays.”

The Supreme Court heard arguments Tuesday in support of the 2007 Vermont statute limiting the release of the information detailing which drugs doctors prescribe. This information is maintained by pharmacies, which sell it to data-mining agencies, that in turn sell it to drug companies, for marketing purposes. Patient information is excluded from the data, doctor’s information is not.

Under the Vermont law, this information can be released only with the consent of the doctor. However, once data collection firms like IMS Health and interested parties like Pharmaceutical Research Manufacturers of America, challenged the statute, the issue became a question of free speech.

In the case of Sorrell v. IMS Health Inc., data-mining firms claim they have First Amendment rights to buy and sell the information for their marketing use.

However, the state’s attorney’s office likened the release of the confidential information to disclosing a doctor’s tax returns, patient files, or a competitor’s business information, arguing that First Amendment rights in the case apply to protecting doctor’s information. But since the information is given away to parties including insurance companies, journalists, and law enforcement, the court wasn’t too convinced.

” … just don’t tell me that the purpose is to protect their privacy,” said Justice Antonin Scalia. “[A doctor’s] privacy isn’t protected by saying you can’t sell it but you can give it away.”

Justice John Roberts said Vermont is trying to reduce health care costs by “censoring” information doctors hear about brand-name drugs, with the intent that they will prescribe more generics, a measure Justice Scalia added was a restriction on free speech.

Vermont Assistant Attorney General Bridget Asay responded that “the purpose of the statute is to let doctors decide whether sales representatives will have access to this inside information” on the prescribing habits of physicians.

In an age in which personal data can mined through social networks and search engines, this case could set the precedent concerning how much personal information can be used for marketing. A decision is expected by June.

Dr. Paul A. Offit‘s new book documents the history of his detractors. The pediatric infectious disease specialist and vaccine researcher is a vocal vaccine advocate who has become a target for people who believe that vaccines cause autism and other ills in children. His new book, “Deadly Choices: How the Anti-Vaccine Movement Threatens us All,” follows his 2008 book, “Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure” which focused specifically on the autism accusation.

The new book takes a broader historical view of the anti-vaccine movement, going back to the mid-1800’s in England, when some people actually expressed the fear that the bovine-derived smallpox vaccine would turn their children into cows. “If you look at the messaging and the style of those campaigns, it’s almost identical to today,” Dr. Offit told me in an interview, noting that he hopes the book will put the current anti-vaccine movement into perspective for physicians as well as lay readers.

Dr. Paul A. Offit / Photo by Miriam E. Tucker

According to the book, America’s modern-day anti-vaccine movement began on April 19, 1982, with the airing of “DPT: Vaccine Roulette,” a one-hour documentary on Washington, D.C.’s local NBC affiliate WRC-TV. It described children with a variety of mental and physical disabilities that their parents blamed on the diphtheria-tetanus-pertussis vaccine. The book also discusses today’s anti-vaccine crusaders, including celebrities such as Jenny McCarthy, Jim Carrey, and Bill Maher.

The book is intended to sound an alarm.“The problem with choosing not to vaccinate is not theoretical any more. I think we’re past the tipping point. We’ve had outbreaks of whooping cough, measles, and mumps and even bacterial meningitis that are preventable, because people are choosing not to vaccinate. They’re so scared that they’re more frightened of the vaccine than of the disease…I just think someone has to stand up for these children who are suffering and being hospitalized and dying,” he told me.

Dr. Offit is often attacked on the Internet by people who oppose vaccines, and once received a death threat by email. In June 2006, I was among the attendees at a meeting of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices who had to navigate through a crowd of anti-vaccine protestors lining the sidewalk leading to the CDC’s main Atlanta campus. One protestor held a sign labeling Dr. Offit a terrorist. Another yelled at him through a megaphone, calling him the devil.

I asked if he’s worried about a similar reaction to the new book. “I don’t think it will evoke any more anger than I’ve already evoked,” he replied.

Dr. Brook is professor of pediatrics at Georgetown University, Washington, and a specialist in anaerobic bacterial infections and infections of the head and neck. He was diagnosed with hypopharyngeal squamous cell carcinoma in 2005, despite never having smoked. Surgical removal of the tumor and radiation were initially successful, but 2 years later, the cancer recurred and he underwent total laryngopharyngectomy.

In his new book, “My Voice: A Physician’s Personal Experience With Throat Cancer,” Dr. Brook recounts, in unflinching detail, the 3 years beginning with his diagnosis and culminating in his newfound role as a spokesman bridging the gap between medical professionals and patients with head and neck cancers, particularly laryngectomees.

Being a physician did not prevent Dr. Brook from experiencing the same fears and emotions felt by any patient diagnosed with cancer. He relates these throughout the book, including his initial “inner prejudice about patients with cancer” dating back to his medical school days decades earlier when the diagnosis meant a near-certain death sentence.

Nor did possession of a medical degree protect Dr. Brook from medical errors. It just allowed him to spot more of them. Indeed, a startling proportion of the book chronicles the numerous errors — of both omission and commission — that he observed during each of his hospital stays. The majority of these — some with serious consequences — would not likely have been detected by patients without medical backgrounds.

Photo by Miriam E. Tucker

Following his radical surgery, Dr. Brook struggled to communicate with busy, overworked physicians and nurses. Describing morning rounds, he writes, “When the surgical team arrived and departed within 2 or 3 minutes without giving me time for follow-up questions, I felt ignored and frustrated … I was also afraid that if I antagonized them, I would receive even less attention.”

But his account isn’t all negative. Throughout the book, Dr. Brook praises the many “compassionate” medical professionals involved in his care — including even some who made mistakes — and documents his personal triumphs and insights in adapting to his new set of realities. He now shares his expertise with fellow laryngectomy patients at the online support community www.webwhispers.org.

Before his ordeal began, Dr. Brook had been a worldwide lecturer in infectious disease. Now that he uses a voice prosthesis and speaks in a “rusty whisper,” he’s found a new mission. “My wish is to use this obstacle in my life in a positive way. By lecturing and writing about my experiences and sharing them with other laryngectomees and health care providers I hope that others will learn and benefit from my experience.”

The book is available in paperback and e-version. All proceeds go to 9114HNC, a fund that grants financial aid to patients with head and neck cancer.

National health officials are encouraging all Americans older than 6 months to get vaccinated for the flu this year (read the story). The recommendation was announced during an influenza press conference sponsored by the National Foundation for Infectious Diseases.

This year we think that the three strains of influenza in the flu vaccine are going to be excellent matches with the flu that’s circulating.

Our reporter Heidi Splete was at the press conference and spoke with Dr. Daniel Jernigan, who is the deputy director for the CDC′s influenza division, about why it’s important for physicians and their staff to be vaccinated against the flu. She also spoke with Dr. Judith S. Palfrey, immediate past president of the American Academy of Pediatrics, about giving the flu vaccine to children at the same time as other vaccines. Finally, she spoke with Dr. William Schaffner, president of the NFID, about the availability of the the flu vaccine at grocery and drug stores.

Routinely sleeping as little as 5 to 6.5 hours per night appears to have no affect on longevity, according to results from a subset of women who participated in the Women’s Health Initiative.

The finding conflicts with many previously published studies which suggest that sleeping 6.5 to 7.5 hours per night is associated with optimal survival.

For the study, which was reported online Sept. 30, 2010, in the journal Sleep Medicine, researchers led by Dr. Daniel F. Kripke, professor emeritus of psychiatry at the University of California, San Diego, revisited original research conducted between 1995 and 1999, in which 459 San Diego women aged 50-81 years were monitored with actigraphy for 1 week to determine if nightly sleep duration was associated with mortality.

Fourteen years later, the researchers were able to locate and evaluate 444 of the women initially enrolled in the study. Of these, 86 had died (J. Sleep Med. 2010 Sept. 30 [doi: 10.1016/j.sleep.2010.04.016]).

Dr. Kripke and his associates found that the best rates of survival occurred among women who slept 5 to 6.5 hours per night. “Women who slept less than 5 hours a night or more than 6.5 hours were less likely to be alive at the 14-year follow-up,” Dr. Kripke said in a prepared statement.

It’s unclear if any of the study participants were enrolled in medical residency programs at the time.

So, be honest here. On average, how many hours per night of sleep do you get?